The paradox of paradoxical insomnia: a theoretical review towards a unifying evidence-based definition
Abstract
Paradoxical insomnia is one of the most intriguing yet challenging subtypes of insomnia. Despite being recognized for a long time by the international community, it is still unclear whether this entity really exists, which are its features and boundaries. Much of the debate is fuelled by the lack of a consensus on its precise definition. To help filling some of the existing gaps, a systematic review of the literature was conducted, through which 19 different quantitative definitions were obtained. These definitions were then applied to two distinct datasets. The first consisted of 200 chronic primary insomnia patients, diagnosed according to the DSM-IV-TR criteria. The second consisted of 200 age- and sex-matched healthy persons without insomnia. For each dataset, available data from the objective sleep parameters and their subjective estimation were imported and analysed in MATLAB. Depending on the definition used, the prevalence of paradoxical insomnia ranged from 8 to 66%, while agreement between different definitions ranged from -0.19 to 0.9 (using Cohen's kappa coefficient). Based on the results garnered, necessary features for a quantitative definition of paradoxical insomnia were identified. Several open questions remain, such as whether there is a minimum number of hours a patient should sleep to fulfill the criteria for a diagnosis of paradoxical insomnia, and whether sleep latency can be used in the definition along with total sleep time. We conclude by advocating continued study of paradoxical insomnia and sleep state misperception and by providing specific directions for future research. STATEMENT OF SIGNIFICANCE: The current understanding of paradoxical insomnia and, more broadly, of sleep state misperception, is greatly hampered by the lack of agreement on a quantitative and evidence-base measure of the discrepancy between subjective and objective sleep evaluation. The current study provides a critical analysis about the strength and the limitations of the available definitions, using both a data-driven and a theory-driven approach. The overarching goal is to motivate a rigorous discussion involving the main experts of the field, to build a consensus, and develop an evidence-based measure of sleep state misperception and/or of paradoxical insomnia.
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The observed discrepancies between self-reported and objective sleep outcomes could be related to paradoxical insomnia, a subtype of insomnia where individuals perceive that they sleep considerably less than when measured objectively.
“The observed discrepancies between self-reported and objective sleep outcomes could be related to the commonly reported phenomenon of paradoxical insomnia, a subtype of insomnia where individuals perceive that they sleep considerably less than when measured objectively (116).”
From Interventions for insomnia in cancer patients and survivors-a comprehensive systematic review and meta-analysis (2024) · cites this paper as [116]
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- Authors
- Castelnovo, A., Ferri, R., Punjabi, N. M., Castronovo, V., Garbazza, C., Zucconi, M., Ferini-Strambi, L., & Manconi, M.
- Affiliations
- Ospedale regionale di Lugano (CH)
- I.R.C.C.S. Oasi Maria SS (IT)
- Johns Hopkins University (US)
- Vita-Salute San Raffaele University (IT)
- Corresponding author
- Castelnovo, Anna
- Manconi, Mauro
- Venue
- Sleep Medicine Reviews
- Publisher
- Elsevier BV
- Published
- 2019-04
- Volume
- 44
- Pages
- 70-82
- ISSN
- 1087-0792 (ISSN-L)
- OpenAlex
- W2906076759
- Cited by
- 99
- References
- 67
- Citations by year
- 2026: 15 · 2025: 14 · 2024: 15 · 2023: 16 · 2022: 18 · 2021: 10 · 2020: 9 · 2019: 2
- FWCI
- 0.84
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Sleep Medicine Reviews (publishedVersion)
- PubMed (publishedVersion)
- Archivio Istituzionale della Ricerca - Università Vita-Salute San Raffaele (submittedVersion)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- paradoxical insomnia, sleep state misperception, insomnia subtypes, chronic primary insomnia, subjective-objective sleep discrepancy, total sleep time, sleep latency, diagnostic criteria, prevalence
- MeSH terms
- Sleep Latency, Humans, Sleep Initiation and Maintenance Disorders, Polysomnography
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